NCLEX-RN
Health Promotion and Maintenance NCLEX RN Questions Questions
Extract:
Question 1 of 5
A nurse is assessing a client's pulse oximetry on the surgical unit. As part of routine interventions, the nurse turns off the exam light over the client's bed. Which of the following best describes the rationale for this intervention?
Correct Answer: A
Rationale: When assessing a client's pulse oximetry values, the nurse should turn off any extra environmental lights that are unnecessary, including exam lights or over-bed lights. External light sources may cause falsely high oximetry values when the extra light interferes with the sensor of the oximeter, leading to inaccurate readings.
Choice B is incorrect because a bright light in the client's face would not directly affect the pulse oximetry values.
Choice C is incorrect as external light sources typically cause falsely high, not low, oximetry values.
Choice D is incorrect as the primary reason for turning off the light is to prevent falsely high readings, not solely for the client's comfort.
Question 2 of 5
A client is being monitored for decreased tissue perfusion and increased risk of skin breakdown. Which measure best improves tissue perfusion in this client?
Correct Answer: B
Rationale: For a client at risk of impaired skin integrity due to decreased tissue perfusion, improving mobility is crucial to enhance tissue perfusion and prevent skin breakdown. Range of motion exercises are beneficial to increase circulation and prevent complications. Massaging reddened areas may further damage fragile skin. Administering antithrombotics may be necessary for specific conditions but does not directly address tissue perfusion. Feeding a high-carbohydrate diet does not directly improve tissue perfusion in this context.
Question 3 of 5
A client diagnosed with heart failure and secondary hyperaldosteronism is started on spironolactone to manage this disorder. The nurse informs the client that the need for dosage adjustment may be necessary if which medication is also being taken?
Correct Answer: C
Rationale: Spironolactone is a potassium-retaining diuretic. If the client is also taking potassium chloride or another potassium supplement, the risk for hyperkalemia exists. Potassium doses need to be adjusted while the client is taking this medication. A dosage adjustment would not be necessary if the client was taking alprazolam, warfarin sodium, or verapamil hydrochloride.
Question 4 of 5
The nurse caring for a client in labor should plan to assess the fetal heart rate (FHR) at which specific times? Select all that apply.
Correct Answer: A,B,C,E
Rationale: Assessment of the mother and fetus is continuous during the process of labor. However, for all clients, the FHR needs to be assessed before ambulation; immediately after vaginal examinations, rupture of the membranes, or any other invasive procedure; and before the administration of oxytocin because these activities or situations can cause alterations in the FHR. The FHR is also assessed in between contractions, during the contraction, and for at least 30 seconds after the contraction. It is not necessary to assess the FHR before turning the client to her side.
Question 5 of 5
A client has been administered ketamine by a physician in preparation for general anesthesia. Which of the following side effects should the nurse monitor for in this client?
Correct Answer: A
Rationale: Ketamine is an anesthetic that induces dissociation and lack of awareness in a client. It can be used before general anesthesia or during short procedures for sedation. Ketamine may lead to side effects such as delirium, hallucinations, hypertension, and respiratory depression.
Therefore, the nurse should monitor the client for delirium, as it is a potential side effect associated with ketamine use. Muscle rigidity, hypotension, and pinpoint rash are not typically attributed to ketamine administration and are less likely to occur in this scenario.